General Practice - Recovery Consolidated Guidance for Practices 2021

Primary Care Team – Working Together

Additional Guidance and Support Version 0.1 26 April 2021

Section 1 Introduction and the Patients Perspective 4 1.1 Introduction 1.2 The Patients Perspective – the findings of the Health and Social Care Alliance Scotland

Section 2 Managing Health and Safety, Infection Control & PPE, Risk and Business Continuity. 6 Risk and Business Continuity 2.1 Health and Safety Responsibilities 2.2 Infection Control and Training 2.3 PPE 2.4 Public Health – Primary Care Guidance

2.5 Managing the Environment 2.6 Managing Risk 2.7 Business Continuity Planning

Section 3 Managing Demand, Access and Care Navigation 14 3.1 Patient Access 3.2 Triage vs Screening 3.3 Practice Front Door - Open or Closed? 3.4 Care Navigation 3.5 Managing Prescriptions, Appointments, Serial Prescribing and Test Results to Reduce Footfall 3.6 Covid Assessment Centres (CACs) 3.7 Patient Registrations

Section 4 Managing the Workforce and Staff Welfare 19 4.1 Managing the Workforce 4.2 Staff Welfare

Section 5 Near Me 21

Section 6 Managing Public Messaging and Communication 22 6.1 National Messaging 6.2 Practice Messaging

Section 7 Summary and Conclusion 25

Appendices Appendix A – ALLIANCE Primary Care Report Appendix B - Scottish Government Driver Diagram Appendix C – FAQs and Resources Appendix D – What is TURAS learn Appendix E – Example of Telephone, Video & Face to Face Appendix F – Engaging with the Team and Managing Change Appendix G – Pentlands Medical Practice Reflections

Section 1 Introduction and the Patients Perspective 1.1 Introduction

In the past year general practice teams have risen to the challenge of dealing with the Covid-19 pandemic, adapting services to meet patient demand and developing innovative ways of working. This has required clear leadership, determination and flexibility.

Re-mobilise, Recover, Re-design, published in May 2020, set out the Scottish Government’s plans to restart as many aspects of our NHS services as possible. It set out that restoring normal services should mean capitalising on the gains we have made in new ways of working, prioritisation and collaboration, with the roll-out of new techniques, technology and clinically safe but faster pathways to care for patients.

We undoubtedly face significant challenges going forward. To step up to meet these challenges, we must look to the achievements and successes of those working in general practice during this challenging period and to celebrate areas of innovation and good practice to meet the needs of the public (patients) and practice teams.

This document brings together (and signposts to) current guidance to ensure that good practice is shared, and questions answered so that the way forward becomes clearer and general practice is supported to continue to deliver the high level of care it has always provided, but in a different way.

It has been designed as a “work in progress” in order to receive feedback from practices and to allow for further expansion in future versions (for example - long term condition management) as more examples of good practice are shared and questions answered. The contents are by no means prescriptive as there is recognition that practices across the country are managing different challenges with diverse patient populations in different ways so each practice will need different solutions, but we hope this document will give you and your team ideas and suggestions of things you may want to consider in your practice.

This document will be supported by a series of webinars (MS Teams live events) provided by NHS Education Scotland (NES), Health Improvement Scotland (HIS) and Scottish Government working collaboratively.

This document is not a substitution for any other form of Covid-19 guidance and one of the risks in operationalising guidance is that guidance is regularly changing. Therefore, it is strongly recommended that practices have their own operational plans in place which are reviewed and updated regularly following appropriate national guidance provided by Scottish Government and Public Health Scotland (PHS).

Please submit your feedback, any further questions, and examples of further good practice to: [email protected]. If you require any additional advice or have future training requirements, then please let Charlotte know.

1.2 The Patients Perspective - the findings of ALLIANCE Scotland

Recent work by the ALLIANCE, which reported on patients experience of accessing care during the pandemic , not only highlighted the many positive experiences patients had accessing care but also some less than positive examples were also cited by both patients and staff. Therefore, as we move forward, it will be important that we all engage and communicate with patients about what, how and why services are being delivered both at a national and local level. In addition the ALLIANCE have reviewed these findings specifically for Primary Care and these findings are attached in Appendix A. .

The Scottish Government has produced a “driver diagram” to support this work (Appendix B). The overarching aim of this work is: “People will always be able to access the health and care services that are right for them, at the right time, from the right place”, with outcomes seeking to improve the patient experience, reduce complaints and increase staff job satisfaction. The diagram highlights change ideas, building on areas that practices have been developing over the last ten years, namely the patient safety agenda, the continued need to avoid harm, ensuring an equitable, flexible service for patients, and for practices to continue to develop processes and systems which learn from improvements and share good practice. The overall intention is to support accessibility and continue to deliver high quality, person centred care that meets the needs of practice populations and practice teams.

A number of organisations can provide support for practices to make these drivers a reality including: NES (in particular the Practice Manager and GPN networks), HIS and the work of the Practice Administrative Staff Collaborative (PASC), on-going patient engagement through the work of the ALLIANCE, NHS inform (NHS24), SGPC (BMA) and RCGP.

In addition to this recovery plan, on-going work on the implementation of the 2018 GP Contract and the transformation of Primary Care will continue.

Realistic Medicine and the Chief Medical Officers (CMO) annual reports provide some overall themes to support delivering person centred care and engaging with patients in a patient centred way including shared decision making.

Section 2 Managing Health and Safety, Infection Control & PPE, Risk and Business Continuity. 2.1 Health And Safety

GPs, General Practice Nurses and other professionals need no reminder of their professional responsiblities in relation to their role as a clinician. But GP Partners as independent contractors (who are the employers of the staff) also have other responsiblities. These responsiblities have been in existance for many years but, given the nature of the pandemic, it is worth re-emphasising those responsiblities which relate specifically to Health and Safety.

General practice, like any other business in the UK, is governed by the Health and Safety at Work Act 1974 (the Act) which places a duty on employers to ensure that their workplaces are safe. The Act requires all businesses and employers to: ▪ Appoint a responsible person ▪ Provide information and training to staff ▪ Provide insurance ▪ Provide facilities such as toilets ▪ Provide first aid ▪ Undertake risk assessments ▪ Provide a health and safety at work policy and to display the appropriate poster ▪ Report accidents and illnesses

All of the above requirements of the Act should be very familiar to practices and practice managers and are expanded further in Health and Safety Made Simple.

However, in relation to Covid-19 there are additional areas that practices (and any other business in Scotland) now have responsibility for, namely: ▪ Risk assessments specific to Covid-19 ▪ Social distancing ▪ Cleaning, hygiene and handwashing ▪ Ventilation and air conditioning ▪ Working from home ▪ Vulnerable workers

Further information can be found below: Making your workplace COVID-secure during the coronavirus pandemic (hse.gov.uk) https://www.gov.scot/publications/coronavirus-covid-19-safer-work-places-statement/

Although the Covid-19 pandemic has not provided any prescriptive or mandatory training for clinical and other staff within a GP practice, business compliance with the Act mandates that all businesses must comply with the new Covid-19 measures as above and provide the necessary training and information to their staff.

2.2 Infection Control

Infection Control Manual: Infection control measures for the Health Service in Scotland are written by ARHAI (Antimicrobial Resistance and Healthcare Associated Infections) colleagues who sit within National Services Scotland (NSS). Over the last year they have been responsbile for reviewing and updating the infection control guidance for both community (primary) and secondary care at a national level and providing advice to local Health Board health protection teams on matters relating to infection control.

The Infection Control Manual, Section 7 pertains to community care settings (which covers GP and other Primary Care settings). This should not be confused with section 5 which covers the acute and secondary care settings.

The Infection Control Manual has been in existance and applicable to Primary Care settings since 2012 and all staff should comply with the infection control measures within. It is likely that much of the information from within the manual, pre Covid-19, would have been found within practices health and safety policies and the focus would likely have been concerned with hand hygiene, sharps management and clincial waste disposal. Your staff may well have complied very well but possibly did not know the origins of the information with which they were complying.

The most pertinent information within the document for general practice is that relating to PPE which is necessary for all clinical staff (see section 2.3 of this guide), cleaning recommendations (see section 2.5 of this guide) and the wearing of face coverings by the general public when accessing practice buidlings. In addition there are FAQs provided in Appendix C

At the time of writing there has been some confusion about the wearing of face coverings by the general public when accessing Primary Care Premises. The Infection Control Manual states:

“The extended use of facemasks by health and social care workers and the wearing of face coverings by visitors is designed to protect staff”.

Therefore, face coverings (and not facemasks) for members of the public accessing Primary Care premises are adequate. Guidance should be regularly reviewed for any changes.

All Staff: The Infection Control Manual should be familiar to all staff in the practice and the practice has a duty to provide this information and related training under the requirements of the Health and Safety at Work Act. Section 7 describes those areas that apply particularly to community care settings (including GP practices) and staff should be encouraged to familiarise themselves with the areas that affect their roles (and from this link you can access the rest of the document).

Follow FACTS and Socially Distance:

All staff should still comply with FACTS where at all possible: F – face coverings (or a medical grade mask from your PPE stock if entering a clinical area) A – avoid crowds C – clean hands T – Two metres S – Self Isolate

FACTS Posters for the practice are available in different languages.

Alongside the Covid-19 vacination programme, all members of the public are still being asked to follow FACTS as part of a range of mitigation measures. Therefore, members of the public should still wear face coverings, clean hands and remain at 2 metres when in the practice. Continuing to provide hand gel or a place where patients and staff can wash their hands and keeping chairs at 2 metres in waiting rooms, offices and break rooms, where possible, is still important. Screens separating reception staff from patients are still a good idea.

Further information about managing your environment can be found in section 2.5 of this guidance below.

Displaying posters at the front door reminding patients of FACTS is still good practice as well as asking them not to attend if they have any of the three key symptoms of Covid-19: temperature, cough or asnosmia (loss of taste or smell).

Clinical Staff Training: In addition to the above, all clinical staff should have access to training on infection control and be encouraged to participate.

There are good Infection Prevention and Control resources for all members of the team and training is provided at Foundation, Intermediate and Improver level. There are training modules on handwashing and PPE donning and doffing.

Signing up for a NES Turas account is a good idea for all staff as there are many resources and training materials and courses within Turas. See Appendix D

Car Sharing: Car sharing should be avoided. However, when car sharing is necessary and unavoidable, such as with medical students on placement, this guidance should be followed.

Posters and Leaflets: There are many good resources in the Infection Control Manual including posters which may be suitable for displaying at entrances to buildings.

2.3 PPE

NSS is continuing to provide the necessary PPE to Primary Care contractors. Initially this was via a “push” model whereby estimated amounts of PPE were delivered via Health Boards to practices but over the last 4-5 months a “pull” model has been implemented in many Health Boards whereby practices can now order via PECOS the PPE that they require. This does mean that practices need to establish an internal system for stock management, storage and ordering to ensure that they do not run short. NSS recommends ordering for a four-week period.

The current PPE requirements for practices can be found in Section 7.5 of the Infection Control manual.

This splits PPE effectively into two categories: treating medium and high risk.

Within section 7.2.6 a detailed explanation is provided for both categories but essentially:

• HIGH is for those patients who currently have Covid-19, any Covid-19 symptoms, those who are suspected of having Covid-19 or those who have had contact with someone with Covid-19 and are within the 14 days isolation period.

• Medium is for those who have no Covid-19 symptoms or have recovered from Covid-19.

With the above categories in mind, clinicians are required to risk assess the individual situation to reach a decision on what PPE they need to wear.

In a HIGH risk category, where a patient cannot be treated at a Covid-19 assessment centre, it is recommended to wear all four pieces of PPE.

In a MEDIUM risk category, a mask may be sufficient, unless there is likely to be exposure to blood and bodily fluids (BBF) in which case apron, gloves and eye protection may be required with gloves and apron used on a single use basis.

Table 2 is provided below and can also be found in the Infection Control Manual.

Table 2: PPE for direct individual/patient care determined by risk category

PPE used Medium-risk category High-risk category Gloves If contact with BBF is anticipated, Worn for all direct care. then single-use. Single use. Apron or gown If direct contact with patient, their Always within 2 metres of patient environment or BBF is anticipated, (Gown if splashing spraying (Gown if splashing spraying anticipated). anticipated), then Single use. Single-use. Face mask Always within 2 metres of a patient Always within 2 metres of a patient - - Type IIR fluid resistant surgical Type IIR fluid resistant surgical face face mask mask Eye and face If splashing or spraying with BBF, Always within 2 metres of a patient protection including coughing/sneezing anticipated. Single-use, sessional or reusable following decontamination. Single use or reusable following decontamination.

Type IIR facemasks should be worn for all direct care regardless of the risk category. This is a measure which has been implemented alongside physical distancing specifically for the Covid-19 pandemic. FRSMs should be changed if wet, damaged or soiled.

Staff should wear face masks if entering a clinical area and face coverings, in accordance with the FACTS guidance, should be worn at all other times except when eating.

Within the Infection Control Manual there is additional guidance on sessional use and disposal and all those using PPE should read the manual.

In order to make the operational running of the practice as smooth as possible, practices may want to change the running order of the day so that any patients in the high risk category are seen at the end of surgery or later in the day (see Section 2.5 Managing the Environment) apart from more urgent scenarios.

2.4 Public Health – Primary Care Guidance

(currently under review and will be republished shortly as Guidance for Healthcare Settings)

PHS has responsibility for writing guidance for health care settings and the most recent version is Covid-19 Guidance for Primary Care.

Guidance is updated on a regular basis so it will be important for someone in the practice to be checking updates and versions on a reasonably regular basis.

The current version of the guidance is 13.3 and was published on 1 April 2021. The principle change is:

Access for Patients 7.1 Patients who, following telephone assessment, do not meet the possible case definition for Covid-19, and who require further face to face meeting/consultation, should be advised to attend the healthcare facility/premises for further management.

This does not mean that all patients should be seen face to face, and while we remain in the pandemic, social distancing and other infection control measures should remain in place, but practices are encouraged to consider who, and when patients, should be seen face to face, and how to effectively communicate this with your patients, based on the principles of Realistic Medicine and shared decision making. There is still feedback from patients who are struggling to understand when they can and can’t see a health professional face to face. As mentioned previously, clear, simple communication and regular patient engagement are key to managing such changes.

2.5 Managing the Environment

Cleaning Advice on cleaning a building can be found in the Infection Control Manual in Section 7.7.

Cleaning of transition touch points (for example door handles) and clinical rooms should be undertaken in accordance with guidance. If feasible, see high risk patients towards the end of the day when the room is likely to be cleaned again by the practice cleaners.

The above advice is no substitute for reading the complete guidance and the Infection Control Manual provides additional, more substantive information, and is continually under review.

Two metre distancing The Scottish Government is still asking all people to follow FACTS which requires people to follow the two metre social distancing guidance. For non-public services, like churches, and museums there is very specific draft guidance which has just been published and whilst this does not apply to those providing an essential public service, there are still a number of key points which you may want to consider including:

• Pinch points – at entrances and exits to buildings it is worth reminding people of FACTS by displaying appropriate posters. You may also have pinch points in corridors or at the front reception desk so marking out two metres for

queues is a good idea. Avoiding queues building up, if at all possible, and creating one-way systems for entry and exit can also help to avoid gatherings. Try to avoid gatherings in office spaces and coffee rooms which may also be tight on space. You may need to stagger coffee and lunch breaks.

• Use of temperature reading guns/machines – as not every patient who has Covid-19 presents with a temperature, the use of such guns to screen patients may not suffice as an adequate screening tool and may provide a false reading. Guns are also subject to environmental influences and so may not provide an accurate reading. Screening questions by staff (as described previously) are the best option along with posters at the front door, messages on phone systems and information on websites asking people not to attend if they have any of the three key symptoms.

• Ventilation – as we move into the summer it is easier to keep doors and windows open to allow for a good flow of fresh air through the building. Good ventilation is one of a range of mitigation measures recommended to mitigate against Covid-19 spread. The use of desk and standing fans to achieve appropriate air flow is not recommended.

• Face Coverings – FACTS still require members of the public and staff to wear face coverings. Staff should wear face masks upon entering a clinical area such as a consulting room and a face mask or face covering in office and reception spaces.

• Hand Hygiene – providing toilet facilities where people can follow good hand hygiene is important. Hand gel can also be provided in waiting rooms, offices and break rooms.

• Provision of Information – reviewing information regularly as the situation concerning the pandemic changes and providing information to the public about what is expected of them when attending the practice is very important, so make good use of:

• clear messaging on practice phone systems • clear information on practice websites • screening by staff when making appointments (for the 3 key symptoms) • clear information provided by staff on what can be expected when people attend for an appointment • good clear signage around the building • 2 metre distancing tape can be used on the floor to manage queues • display posters at entrances • screens at front reception • information and arrows if you are using a one-way system

2.6 Managing Risk

Under the Health and Safety at Work Act, all businesses have a duty to manage risk in their own environment so having read and digested the guidance available it would be advisable to carry out a Covid-19 risk assessment to ensure that you have complied as far as you can in order to minimise risk to both staff and the attending public. NES has produced some useful tools and a readiness check list.

2.7 Business Continuity Planning

It has previously been recommended that Practices review their business continuity plans to ensure they are up to date. Further information can be found on the RCGP website. As the vaccination programme rolls out it becomes less likely that a whole practice will close because of a Covid-19 outbreak. However, having seen this happen to some practices in the past year, being prepared is important. A practice business continuity plan is good practice in normal circumstances and should be reviewed on a regular basis.

Section 3 Managing Demand, Access and Care Navigation 3.1 Patient Access

Over the last year, practices have offered very different ways of managing patient access, primarily because they have been telephone triaging most people who phone in seeking an appointment or advice. For many practices this has involved GPs and Nurses carrying out the triage role with a greater emphasis on telephone and video (Near Me) consultations and a lesser emphasis on face to face appointments. For some, where a mix of appointments was offered pre-Covid-19, this may not have been a huge change for the staff nor the patients. But for others, this has been a radical change process delivered at speed which possibly had little time for planning nor appropriate messaging at the time that it was introduced.

The ALLIANCE report on people’s experiences of accessing GP services during the pandemic reflects this mixed approach with some people praising their GP surgeries for the work undertaken in the last year with others expressing less positive experiences reflecting the inconsistence in approach. Anecdotally there also appears to be an increase in patients complaints, and aggressive and occasionally violent situations against practice staff. This is not acceptable, but we need to consider why this is happening as well as how these situations should be managed if / when they do happen. Practices should consider how they can learn and adapt from these situations, including the learning from complaints and patient feedback.

It’s important to recognise that no one system is going to suit all people or all clinical issues. Whilst many patients like the use of technology like Near Me and telephone consultations, for other people and clinical situations, these may be highly unsuitable.

It will be important as we move forward, to find longer term solutions to offer choice in order to maximise on the gains we have made in terms of technology whilst also reflecting and recognising that not all new ways of working provide appropriate access for everyone nor every clinical situation.

At the beginning of the pandemic practices were able to leave their doors open but some closed their doors and moved to practice business taking place on-line or over the phone which reflected the logistics of managing a reception in line with infection control measures at the time. This posed challenges to patients who were trying to access services particularly where the change hadn’t been communicated clearly or effectively.

Version 13.3 of the Public Health Primary Care Guidance (1 April 2021) has changed the emphasis, removing the recommendation to triage thus offering practices the opportunity to review their access options for patients. The guidance states:

Patients who, following telephone assessment, do not meet the possible case definition for COVID-19, and who require further face to face meeting/consultation, should be advised to attend the healthcare facility/premises for further management.

Moving forward, offering a choice of appointment types allows workload to be planned and time allocated to each patient. This could be by telephone, Near Me, asynchronistic consulting e.g. eConsult or in person depending on the problem. The face to face assessment could be after ascertaining by administration staff that the problem does not relate to acute Covid-19 symptoms. Practice protocols, staff training, patient engagement and communication will be key to success including reducing the number of complaints and concerns raised by the public.

One of the challenges will be establishing true demand for services and the appointment types required due to the enforced changes at the beginning of the pandemic and the subsequent behaviours. One consideration could be to offer ‘generic’ appointment types which are then ‘converted’ depending on what the patient requires. RCGP provides further advice and guidance.

If not already happening, now may be a good opportunity for the practice to start a conversation on what has worked and what has not worked quite so well in the last year in order to plan appropriate access for the future. Reflecting on complaints or comments by patients would be a good starting point. Careful planning, consideration of patient needs, and training of reception staff will be important together with the production of clear protocols for staff to follow including scripts to use when answering the phone.

Further information on engaging with the team and managing change can be found in appendies F and G where practical examples are illustrated.

A GP in Forth Valley, commenting on health inequalities and access “one thing that solidified my understanding of the challenges that faced our patients was looking at data from the local census about education levels, access to phones, single adult households and the number of households with carers”

3.2 Triage vs Screening

As Covid-19 is likely to be with us for some time, screening of patients for the three key symptoms will still be imperative in mitigating the risk of people bringing an infectious disease into the practice unawares. This is something that reception staff can be trained to undertake. Therefore, initial triage by clinically trained staff over the phone may not necessarily be required although for some practices this may still be the preferred option.

Simple screening techniques can be carried out by staff over the telephone or by an initial telephone message. Whilst people should still be seen in a way that minimises risk, we also need to ensure that people get the care that they need when they need it.

3.3 Practice Front door - Open or Closed?

Although some practices locked their doors during the pandemic to mitigate against people coming into the practice off the street without appropriate screening, their intention was that the practice was still open but that they now required patients to telephone in first for further advice. However, for many patients the perception was (and in some cases continues to be) that the practice was closed, and they could no longer access the treatment they needed.

Example - Wendy Calder Practice Manager at Annat Bank and Townhead Practices

Within our building are three practices and an outpatient department, we have never had a locked door, except for 30 minutes at the start of covid and that 30 mins was enough to test the fitness of my colleagues and we decided we would manage the patient flow.

While we had a small number of patients attend without an appointment, they were politely asked to leave and phone the practice. We have a process for sending all prescriptions to the chemist and e-mail those required urgently, forms are available on our website and we have a post box outside the building, sample bottles can be collected. As our staff have mostly had their second covid-19 vaccination along with glass screens installed at reception, we feel these measures have minimised risk.

One year on and there are very few patients who turn up unannounced.

The following may be useful for practice websites or practice phone messages:

• The practice is open, and services are being provided differently ( for more details on the NHS Inform website).

• Patient consultations are now being delivered in a range of ways to help meet the needs of all patient groups including online, telephone, video and face to face.

• Patients may be asked for more information from the practice receptionist to help them navigate to the most appropriate service or professional.

As society opens back up as we head out of the most recent lockdown, practices will need to consider how they appear to their practice populations. It will be important that the practice appears open to the public and practices may wish to consider how they are viewed and valued by their patients and community. Regular communication with your patients and communities will help to build a positive relationship.

The following considerations may help:

• Consider how your patients are feeling and focus on their needs and points of view. (put yourself in their shoes!). • Consider how your patients will interpret your message (both automated and live responses) and be mindful they may not know how your practice works or have difficulty understanding or remembering your systems. Avoid using acronyms they might not understand. Keep it simple! • Avoid blanket statements (e.g., ‘we are not seeing patients face-to-face’) and instead, reassure your patients you are open, treating most patients remotely, and face-to-face appointments are available where clinically necessary. • Engage with your patients when considering your messaging (e.g. your Patient Participation Group, Community Council, patients, carers, family and friends). Your local Community Engagement Officer can provide support and resources to help you engage meaningfully with your patient groups.

3.4 Care Navigation

Drawing on the extensive work and learning from the Practice Administrative Staff Collaborative (PASC), HIS has developed the Care Navigation in General Practice: 10 Step Guide which provides practical guidance on how to set up, or review, care navigation processes and pathways within general practice at pace and scale. It also contains links and references to related support materials developed by our national partners and is accompanied by a recorded workshop which takes you through each step of the guide.

3.5 Managing Prescriptions, Appointments, Serial Prescribing and Test Results – to reduce risk.

Whilst Covid-19 remains within our communities, practices will be keen to reduce risk as much as possible for both staff and patients. It may be clinically appropriate to offer a face to face consultation with a GP or Nurse so when it comes to patients attending for appropriate face to face appointments it may not be possible to reduce footfall.

However, the bulk of prescription requests, making appointments and test results can be handled without most patients having to attend in person so having good systems that are well communicated to patients can reduce footfall in areas where it is not necessary for a patient to attend in person (albeit that a small minority of patients may have no other option but to attend in person). Engaging in serial prescribing can also cut footfall into the practice.

3.6 Covid-19 Assessment Centres

The arrangements for Covid-19 Assessment Centres (CACs) across Scotland are under review and vary from area to area. This may mean that as Covid-19 case numbers drop, we will see the role of the CACs change. For some more rural practices, the nearest CACs have been at some distance, so they have already been seeing some HIGH risk patients who are either Covid-19 positive or have had symptoms. For these practices they may well have had RED and AMBER pathways and have arranged the working day and practice layout to accommodate these situations to mitigate risk as far as possible.

It is worth considering how you could accommodate both MEDIUM and HIGH risk scenarios in the practice (see section 2.5 of this guidance) if you have not already done so. Remaining up to date with patient pathways is imperative as this time of change.

3.7 Patient Registrations

Patients who need to register with a medical practice should be registered as normal. In accordance with a letter dated 14 December 2020 to all practices, registrations can now be done electronically without the need for a patient signature. Further information on registering with a GP practice can be found on NHS Inform. Information for patients on how to register with the practice should be available on your practice website.

Section 4 Managing the Workforce and Staff Welfare 4.1 Managing the Workforce

Staff in the NHS are our greatest asset and resource. Staff turnover and recruitment (and the associated training costs) are things that practices like to avoid wherever possible. Therefore, making the working environment a pleasant place to be is very important. However, we also need to recognise that people have been working extremely hard throughout the last year and that burn out is a real risk.

Because of the nature of general practice, flexibility is required of staff but cannot necessarily be reciprocated as a reward in that staffing requirements are very much defined by the opening hours and the requirement for a “hands on” approach in order to deliver the service.

The pandemic did provide the need for some (shielding) members of staff or those self-isolating to work remotely from home and some practices have embraced the available technology to allow this to happen. There may be room to allow a degree of flexibility going forward to accommodate staff circumstances although this is very much for each practice to decide, dependent on what space you have available in your practice.

Thinking out of the box may be necessary in order to provide staff with the support that they need.

Example – Alison Frankland in Lossiemouth provided time off for a haircut following each of the two lockdowns. A small gesture that was very much appreciated by all staff.

Ensuring that staff can take appropriate rest breaks including annual leave is important in order for them to get a break from work even though they may have no actual holidays away planned. Therefore, proactively managing staff annual leave rather than letting leave accumulate may be prudent.

If you haven’t been able to find time for appraisals in the last year, now may be a good time to schedule these even if these are just an opportunity to catch up with staff to ensure their well-being and reflect on how the last year has been for them, rather than the usual full appraisal which could perhaps wait to a more appropriate time. But ensuring staff feel appreciated, heard and valued just now is important for the whole team.

4.2 Staff Welfare

Staff welfare is something that every practice as an employer has a duty towards their staff and there are resources available to help with well-being. The GP Occupational Health Service available in every Health Board area can be a good source of referral for mental health, stress and anxiety issues particularly where staff may need to take time off as sick leave and to plan a safe return to work and each practice should have its own policy on absence management in place. Now may be a good time to revisit your policies and to review and update where necessary. For everyone in the practice, the following resources may be of help:

o National Well Being Hub o ACAS o NHS Inform o NES o IHUB

Section 5 Near Me

Many practices have adopted the use of Near Me (video conferencing) to some extent during the last year and offer it to patients as a consultation option on a proactive basis. However for those practices who haven’t fully embedded Near Me into their day to day systems and are looking for further guidance and training:

• Near Me guidance • RCGP elearning • Links to Regional Primary Care Webinars delivered earlier this year with GP's describing using Near Me in Practice:

https://youtu.be/wbXSWQfUQGI Western Isles, Shetland & Orkney

https://youtu.be/8FazzSVfGEg Grampian, Forth Valley & Tayside

https://youtu.be/vZXgUipo-BE GGC, Lothian & Fife

https://youtu.be/kXWosnV5KN0 D&G, A&A, Borders and Lanarkshire

• Near Me training videos and bookable "live" training sessions to attend can be found:

https://www.vc.scot.nhs.uk/near-me/training/

A Fife practice has shared their recommendations for telephone, video and face to face consultations and this could be used as a “starter” for a practice discussion on appropriate appointment methods for patients recognising that this type of clinical discussion is never quite as black and white as the example shows (Appendix E ) and would need to be supported with clear staff training.

Section 6 Managing Public Messaging and Communication 6.1 National Messaging

The Scottish Government continues to provide messaging to the general public about services available during the pandemic and the following will be of help to practice staff. Staff should be encouraged to familiarise themselves with such materials. Practices may want to provide links to some of the materials and leaflets on their websites and through their social media accounts.

The Primary Care Digital Communication Toolkit contains information and assets to support communication with the public on how Dental, GP Practice, Optometry and Community Pharmacy services are being delivered differently as a result of coronavirus. This includes: • films on YouTube featuring trusted voices explaining how services are currently being provided; • examples of copy and text that can be used by practices; • information on NHS Pharmacy First Scotland and Scotland’s Service Directory; • a briefing paper on wellbeing and mental health support services for patients, including a range of self-care, clinical and community based options; and • Care Navigation in General Practice: 10 Step Guide (Healthcare Improvement Scotland).

The NHS Inform page Your Community Healthcare Services provides video guides featuring trusted voices explaining how services are currently being delivered by community pharmacy, dental, optometry and general practice. It also sets out person-centred advice and information about: • changes to services due to coronavirus; • self-care, NHS Inform and community pharmacy; • face-to-face appointments, telephone and video consultations; • the role of the receptionist; and • mental health support and NHS 24.

The National door drop (Redesign of Urgent Care) leaflet is a guide to NHS Scotland services, including community pharmacy, general practice, dentistry, optometry, mental health support and urgent and elective care. It also contains information about Covid-19, and how services are being delivered differently.

The Scottish Government have also produced advertorials to promote NHS Pharmacy First Scotland emphasising that this service can provide a convenient alternative to general practice for minor ailments.

6.2 Practice Messaging There are many ways to communicate with your patients and, as discussed at the beginning of this document, when you implement change, communication is key to its success.

Messages for the Team • To ensure consistent messaging, agree as a team how you will support patient access and choice as part of your care navigation activity. • Regularly use all patient feedback, including complaints, to review the effectiveness of your messaging and patient access processes. • Review your messaging platforms regularly (e.g. practice website, voicemail, social media etc.) to reflect both local and national service updates accurately (e.g. Urgent Care, Pharmacy First, It’s OK to Ask). Remember to publicise the content update to assure patients they are accessing the most recent advice. • Collaborate with neighbouring practices, your GP cluster and local partner services such as Community Pharmacy, Dentists and Opticians to ensure consistent and joined-up local messaging. • Use all your communication channels (websites, social media, text messaging practice newsletters etc.) to get the same message(s) across in multiple different ways to reach all your target patient groups.

Making the most of your communication channels Telephone - consider the content and delivery of your automated and live responses. Create an engaging and clear automated message that is concise and easy to understand. Update it regularly with relevant and topical information and consider asking a trusted member of the team to record it. Develop a script for your reception team that clearly explains to patients how the current system is working and anticipate how your patients may respond and what follow-up information you may need to offer. GP practice example telephone messages provides examples of automated messages that patients have responded to positively and Primary Care Communications Toolkit for current national wording templates.

Text Messaging - this is a cost effective and easy way to keep patients updated especially on large-scale communications activities such as vaccination clinics. It can be an alternative to e-mail and is an effective way to deliver appointment reminders and other public health messages. For example, one practice text messaged the link to the NHS Inform Community Services page to all their patients. RCGP provides more information on the benefits and various ways to use text messaging.

Website - Patients of all ages are accessing practice websites more and more and, if used well, can provide them with relevant information while reducing incoming call volume. Regular content management is essential to ensure your website remains accurate so review it regularly, making clear when information was last updated and removing any out of date or expired content. If you do not have a website yet, and have never had a website and wish to consider the GP.Scot website for your Practice please contact [email protected]

Social Media - While not everyone uses social media, many practices have felt significant positive impact from a dedicated social media page such as Facebook, Twitter or Instagram. These platforms can meet the needs of large population groups. The Social Media Highway Code provides more guidance on social media use in healthcare settings.

Example – Gaby Ormerod from Fortrose Medical Practice has set up a facebook page to manage Covid-19 vaccination information which she has combined with telephone invitations.

While setting up and maintaining effective communication between your practice and patients requires planning and ongoing attention, it is worth investing the time as your efforts will support good and in some cases improved patient relations and confidence and may increase clinical and administrative time.

Section 7 Summary and Conclusion

The last year has been difficult for so many people, both those at work trying to manage a fragmented service and for those using these services. Whilst the future is beginning to look a lot brighter with the continuation of the vaccination programme, we now face the challenges of getting society back to some form of normality. The health service is not alone in these challenges which are also faced by the rest of the public sector as well as all commercial businesses, retail outlets and the hospitality sector.

We are all having to manage the additional Covid-19 measures as well as manage a back log of work which will require patience, planning, leadership and empathy.

We should not forget the huge sacrifices that people have made in the last year which has been extraordinary in so many ways. Whereas we were thrown into the pandemic with fast paced change and no time to prepare, we now have the opportunity to redesign services allowing reflection, engagement, planning, communication and delivery.

This will involve engagement from all members of the team to ensure processes and delivery are as smooth as possible for our practice populations, keeping them up to date with the changes that are made over the next few months.

On-going support will be provided to practices by Scottish Government Primary Care Directorate, NES, HIS, NSS, Public Health, the BMA and RCGP in the form of further guidance, updated FAQs, and the continued sharing of good practice via webinars.

This document has been put together with assistance from a number of people and is very much a collaborative effort. As a “work in progress” we welcome your feedback, further questions and thoughts on future training and support.

We would like to thank those practices who kindly agreed to share their ideas and examples.